* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Mycobacterium terrae: a case report
Common cold wikipedia , lookup
Globalization and disease wikipedia , lookup
Transmission (medicine) wikipedia , lookup
Childhood immunizations in the United States wikipedia , lookup
Human cytomegalovirus wikipedia , lookup
Germ theory of disease wikipedia , lookup
African trypanosomiasis wikipedia , lookup
Urinary tract infection wikipedia , lookup
Marburg virus disease wikipedia , lookup
Sarcocystis wikipedia , lookup
Hepatitis C wikipedia , lookup
Sociality and disease transmission wikipedia , lookup
Hygiene hypothesis wikipedia , lookup
Hepatitis B wikipedia , lookup
Schistosomiasis wikipedia , lookup
Coccidioidomycosis wikipedia , lookup
Rheumatoid arthritis wikipedia , lookup
Neonatal infection wikipedia , lookup
Journal of Orthopaedic Surgery 2009;17(1):103-8 Infectious arthritis of the knee caused by Mycobacterium terrae: a case report BW Milne, MH Arnold, B Hudson, MRJ Coolican Royal North Shore Hospital, University of Sydney, Sydney, Australia INTRODUCTION ABSTRACT Mycobacterium terrae is ubiquitous in our environment. M terrae infections most commonly involve tendon sheaths, bones, bursae, and joints. We report a case of infectious arthritis of the knee caused by M terrae in a 21-year-old man who had non-specific chronic synovitis. No organism was seen on microscopy or isolated from cultures until months later. Initially the M terrae culture was considered a contaminant and specific anti-mycobacterial treatment was not advised. The patient was commenced on suppressive therapy for persistent effusion and discomfort. Eventually, the M terrae infection was confirmed and he was commenced on clarithromycin, ciprofloxacin, and ethambutol. The triple antibiotic regimen was continued for 2 years. The knee improved but never completely settled. The patient chose to cease all antibiotic medication. The knee remained swollen and irritable, with little chance of eradicating the organism. Key words: arthritis, infectious; mycobacteria, atypical Mycobacterium terrae complex (M terrae, M nonchromogenicum, and M triviale) has been classified as a non-pathogenic saprophyte, but is increasingly considered a pathogen. It is one of approximately 50 species of atypical mycobacteria or non-tuberculous mycobacteria capable of causing disease. These bacteria are ubiquitous in our environment and produce 6 major clinical syndromes1: chronic bronchopulmonary disease, lymphadenitis, skin and soft tissue disease, skeletal (bone, joint, and tendon) disease, and disseminated and catheter-related infections. The most common presentation of M terrae infection is infection of tendon sheaths, bones, bursae, and joints, usually after direct inoculation. We present a case of infectious arthritis of the knee caused by M terrae in a 21-year-old man. The modes of transmission, difficulties with diagnosis, and treatment options are reviewed. CASE REPORT In April 1997, a 21-year-old man presented with a 10-month history of a painful, swollen left knee. Address correspondence and reprint requests to: Dr BW Milne, Department of Orthopaedics and Trauma Surgery, Royal North Shore Hospital, St Leonards, NSW, 2065, Australia. E-mail: [email protected] Journal of Orthopaedic Surgery 104 BW Milne et al. He had undergone 2 arthroscopies: the first in 1994 for a partial medial meniscectomy after a sporting injury, and the second in February 1995 for a hamstring autograft anterior cruciate ligament (ACL) reconstruction after another sporting injury. The knee was stable but persistently swollen and uncomfortable. An arthroscopy confirmed an active chronic synovitis with a possible granulomatous component. The inflammatory fluid contained no organisms or crystals. No acid-fast bacilli were seen. He gave no history of a penetrating injury to the knee while working as a landscape gardener, and was provisionally diagnosed with an unexplained inflammatory mono-arthritis. Differential diagnoses included sarcoidosis, tuberculosis, and a foreign body synovitis. Further radiographic and serological investigations were unremarkable and he was referred for physiotherapy. Six weeks later, the knee remained swollen and inflamed. An aspiration confirmed an inflammatory effusion with no organisms seen on microscopy. Intraarticular triamcinolone was injected and suppressive therapy with salazopyrin was commenced. 10 weeks later, M terrae was isolated from the culture and the salazopyrin was ceased. An urgent microbiological review and aspiration again yielded no mycobacteria. It was unknown whether the M terrae was a commensal, pathogen or contaminant. The microbiologist was reluctant to prescribe prolonged anti-tuberculous therapy without further bacteriological and histological evidence. The patient therefore underwent a diagnostic arthroscopy and biopsy by an orthopaedic surgeon. Repeat radiographs demonstrated a small cyst in the lateral femoral condyle, minor medial compartment wear, and features of the previous ACL reconstruction (Fig. 1). Bone scans confirmed a mild (a) Figure 1 (b) (c) to moderate diffuse synovitis of the left knee (Fig. 2). In December 1997, the patient underwent a further arthroscopy, synovial biopsy, and arthroscopic synovectomy for moderate synovitis (Fig. 3). Inflammatory fluid and mycobacterial cultures remained negative 12 weeks later. A histopathological examination showed an active chronic synovitis with numerous epithelioid granulomata, which was consistent with mycobacterial infection, foreign body reaction (despite no foreign material on polarisation) or sarcoidosis. Specific anti-mycobacterial treatment was not advised as the original M terrae culture was considered a contaminant. The patient was commenced on suppressive therapy with methotrexate at 6 weeks for the persistent effusion and discomfort, but this was ceased after a 6-month trial as the symptoms persisted. The patient moved out of the area and was referred to a rheumatologist for follow-up. In July 2001, the patient was referred back with a 3-month history of a swollen left knee. The rheumatologist had isolated M terrae from aspirates. Radiographs demonstrated the cystic changes in the lateral femoral condyle and marked swelling consistent with a joint effusion (Fig. 1). His blood tests remained unremarkable. The inflammatory fluid was negative on microscopy but positive on cultures 7 weeks later. He was commenced on clarithromycin and ciprofloxacin before sensitivity results became available. The organism was sensitive to clarithromycin and ethambutol but resistant to ciprofloxacin and rifampicin. Ethambutol was then added. Magnetic resonance imaging at 3 months showed an extensive erosive arthropathy with marked synovial proliferation and erosions in the femoral condyles and posteriorly along both tibial plateaux (Fig. 4). (d) Radiographs of the left knee in (a) April 1997, (b) October 1997, (c) May 2001, and (d) May 2001 (magnified view). Vol. 17 No. 1, April 2009 Infectious arthritis of the knee caused by Mycobacterium terrae 105 Figure 3 Arthroscopy of the left knee in December 1997 showing moderate synovitis. Figure 2 Bone scans in November 1997 showing mild to moderate diffuse synovitis of the left knee. The triple antibiotic regimen was continued for 2 years until November 2003. The knee improved but never completely settled. From December 2002 onwards, improvement was minimal, with a persistent granulomatous synovitis on serial magnetic resonance imaging. In February 2005, the patient underwent synovectomy owing to ongoing pain and swelling in his knee. Once again, the straw-coloured inflammatory fluid collected did not yield any organisms on both microscopy and initial culturing. A histopathological examination revealed a chronic non-caseating granulomatous synovitis. In the early postoperative period, the patient developed a pulmonary embolus and was commenced on warfarin for a 6-month period. 12 weeks later, the cultures became positive for M terrae, which was sensitive to clarithromycin, amikacin, ciprofloxacin, and rifampicin. The patient was re-commenced on clarithromycin, ciprofloxacin, and ethambutol indefinitely. As the effusion remained 6 months later, linezolid (an oxazolidinone) was trialled in combination with clarithromycin and ethambutol, once the warfarin had been ceased. The linezolid was stopped because the patient developed peripheral neuropathy in his legs and clofazimine was then added. This was stopped after 3 months because Figure 4 Magnetic resonance imaging of the left knee in September 2001 showing an extensive erosive arthropathy with marked synovial proliferation and erosions in the femoral condyles and posteriorly along both tibial plateaux. 106 BW Milne et al. of possible adverse effects. In November 2005, the patient chose to cease all antibiotic medication. His knee remained swollen and irritable, and there appeared little chance of eradicating the organism. DISCUSSION M terrae was first isolated in 1950 from radish washings and was thus known as the radish bacillus.2 Based on its laboratory behaviour and culture characteristics, it was classified as non-pathogenic. In 1966, the radish bacillus was isolated from human sputum and gastric lavage samples. This soil organism occasionally inhabits human hosts’ secretions as a non-pathogenic coloniser. It was designated M terrae because of its ubiquitous presence in soil. In 1967, the Centers for Disease Control in the United States reported 5 clinically significant cases of M terrae infection. Over 50 cases of M terrae infection have been reported, involving bone and other synovial structures,3–18 lungs,19–22 skin,19,23 gut,24 urinary tract, lymph nodes or disseminated disease.19,23,25 The most common site is the tenosynovium of the hand and wrist. Two cases of M terrae infection in large joints have been reported. One involved the hip in a 6-month-old infant3 and another involved the knee in a 57-year-old man with rheumatoid arthritis.5 Mycobacterial infection of larger joints is usually due to M tuberculosis or other non-tuberculous mycobacteria such as M intracellulareavium complex, M kansasii or M marinum.5,7,13 Most patients are otherwise healthy with no concurrent medical illnesses or immunosuppression. Inoculation of M terrae usually occurs through direct trauma or a penetrating injury. Direct inoculation is reported in up to 75% of cases.15 In our patient, inoculation was either through the ACL surgery or a minor penetrating injury while working as a landscape gardener. Haematogenous spread from a distant site is possible, but has never been reported in musculoskeletal M terrae infection. Nosocomial infections of atypical mycobacteria have been reported.26,27 They are environmentally ubiquitous organisms and therefore present in most municipal water supplies. A breach of sterilisation protocols is a possible explanation, for example during arthroscopy or the ACL reconstruction. Contamination of medical equipment by tap water during the cleaning process has caused numerous outbreaks and pseudo-outbreaks of non-tuberculous mycobacteria. Inadequate cleaning of instruments, inappropriate disinfectant concentrations, outdated disinfectants, insufficient cleaning time, and the use of tap water can cause a breach in sterilisation. These Journal of Orthopaedic Surgery bacteria are more resistant to elevated temperatures, disinfectants, and ultra-violet light because of their high lipid content and multi-layered cell walls. A rise in the prevalence of such infections has been reported when hospitals lower the temperature in the hot water systems to prevent scalding. Sterilisation equipment should be cleaned and serviced regularly, as mycobacteria can survive in biofilms inside the plastic and rubber tubing. Some atypical mycobacteria are resistant to chlorine, 2% formaldehyde and alkaline glutaraldehyde solutions, organomercurials, and other commonly used disinfectants. Our case was an isolated event with no other atypical mycobacterial infections reported during this period. The sterilisation system used during arthroscopy and ACL reconstruction was the STERRAD Sterilization Systems (Johnson & Johnson Gateway), which has not been linked to atypical mycobacterial outbreaks or pseudo-outbreaks. M terrae infection of synovial structures is difficult to diagnose because it is uncommon and non-specific and is easily mistaken for other systemic or regional rheumatological conditions.4,7,28 Diagnosis can be delayed by use of erroneous or ineffective treatments involving systemic or local corticosteroids, non-steroidal anti-inflammatory drugs, immunosuppressive agents, splintage, physiotherapy, or even amputation.7,8,11 The mean time for diagnosing M terrae infection from symptom onset has been reported as 12.6 months, with more than half taking over 6 months.16 M terrae may not be consistently isolated from tissue or synovial fluid samples; even so it is unknown whether the M terrae is a commensal, pathogen or contaminant. Acid-fast bacilli are often not seen on microscopy and grown in cultures until weeks to months later. The histological appearance of synovial fluid samples is non-specific and can only provide supportive evidence.28 Non-tuberculous mycobacteria should always be considered in the differential diagnosis of a chronic mono-arthritis. Chronic infections of any type should be excluded before injection of, or treatment with, corticosteroids or other immunosuppressives. The criteria for diagnosis of nontuberculous mycobacterial infection are22: (1) repeated isolation of the particular organism at high concentrations over several weeks, (2) manifestation of a disease that could be caused by such an organism, and (3) lack of an associated cause for the disease. It was unknown whether the initial M terrae culture was a contaminent or a pathogen. An outbreak of 163 false positive M terrae infections secondary to contaminated hospital water supply29 and a pseudooutbreak of M terrae secondary to contamination of Vol. 17 No. 1, April 2009 Infectious arthritis of the knee caused by Mycobacterium terrae 107 specimens in the laboratory30 have been reported. A single isolation of M terrae is easily dismissed as a contaminant or non-pathogenic coloniser, because it is ubiquitous in temperate climates. Management of M terrae infection is controversial, with a variety of options reported: surgery alone, antimycobacterial therapy alone, monotherapy or multi-drug therapy, or a combination of surgical and antimycobacterial treatment. A combination of debridement and multiple chemotherapeutic agents for a prolonged period provides the best results.16,17 Initially, our patient responded well to drug therapy alone, thus arthroscopic synovectomy was delayed. The organism was not eliminated, however, despite prolonged antibiotic treatment and multiple arthroscopic synovectomies. M terrae can be multi-drug resistant when cultured. Sensitivity results may vary between laboratories because there is no standardised system for defining organism sensitivity and resistance.1 Sensitivities differ between in vivo and in vitro conditions.16,23 No empirical treatment regimen exists because of the paucity of in vitro testing of M terrae isolates.16 No single agent or drug combination is significantly better than others, but a combination of ethambutol and rifampicin is tending toward significance.16 The in vitro susceptibility testing has found that ethambutol is most effective on agar plates, and in minimum inhibitory concentration studies, semisynthetic macrolides such as clarithromycin are particularly effective, as are ethambutol and aminoglycosides.16 Use of an empirical regimen of clarithromycin, rifampicin, and ethambutol is recommended; it can be altered based on individual sensitivity testing and should be continued for at least 12 months after the first signs of clinical benefit.16 This regimen is also effective for other non-tuberculous mycobacterial infections. In our case, ciprofloxacin was continued despite its in vitro resistance, because in vitro sensitivity testing is not always predictable. Linezolid and clofazimine are useful for treating other mycobacterial infections,31,32 but were not successful in our patient. REFERENCES 1. Brown BA, Wallace RJ Jr. Infections due to nontuberculous mycobacteria. In: Mandell GL, Bennett JE, Dolin R, editors. Mandell, Douglas, and Bennett’s principles and practices of infectious diseases. Vol 2. 5th ed. Philadelphia: Churchill Livingstone; 2000:2630–6. 2. Richmond L, Cummings MM. An evaluation of methods of testing the virulence of acid-fast bacilli. Am Rev Tuberc 1950;62:632–7. 3. Dechairo DC, Kittredge D, Meyers A, Corrales J. Septic arthritis due to Mycobacterium triviale. Am Rev Respir Dis 1973;108:1224–6. 4. Deenstra W. Synovial hand infection from Mycobacterium terrae. J Hand Surg Br 1988;13:335–6. 5. Dijkmans BA, Mouton RP, Macfarlane JD, et al. Bacterial arthritis caused by Mycobacterium terrae. Infection 1981;9:204– 7. 6. Edwards MS, Huber TW, Baker CJ. Mycobacterium terrae synovitis and osteomyelitis. Am Rev Respir Dis 1978;117:161– 3. 7. Fodero J, Chung KC, Ognenovski VM. Flexor tenosynovitis in the hand caused by Mycobacterium terrae. Ann Plast Surg 1999;42:330–2. 8. Halla JT, Gould JS, Hardin JG. Chronic tenosynovial hand infection from Mycobacterium terrae. Arthritis Rheum 1979;22:1386–90. 9. Huskisson EC, Doyle DV, Fowler EF, Shaw EJ. Sausage digit due to radish bacillus. Ann Rheum Dis 1981;40:90–1. 10. Karthigasu KT, Spagnolo DV, Gow BL. Mycobacterium terrae tenosynovitis. Pathology 1990;22:106–7. 11. Kremer LB, Rhame FS, House JH. Mycobacterium terrae tenosynovitis. Arthritis Rheum 1988;31:932–4. 12. Love GL, Melchior E. Mycobacterium terrae tenosynovitis. J Hand Surg Am 1985;10:730–2. 13. May DC, Kutz JE, Howell RS, Raff MJ, Melo JC. Mycobacterium terrae tenosynovitis: chronic infection in a previously healthy individual. South Med J 1983;76:1445–7. 14. Mehta JB, Hovis WM. Tenosynovitis of the forearm due to Mycobacterium terrae (radish bacillus). South Med J 1983;76:1433– 5. 15. Rougraff BT, Reeck CC Jr, Slama TG. Mycobacterium terrae osteomyelitis and septic arthritis in a normal host. A case report. Clin Orthop Relat Res 1989;238:308–10. 16. Smith DS, Lindholm-Levy P, Huitt GA, Heifets LB, Cook JL. Mycobacterium terrae: case reports, literature review, and in vitro antibiotic susceptibility testing. Clin Infect Dis 2000;30:444–53. 17. Zenone T, Boibieux A, Tigaud S, Fredenucci JF, Vincent V, Chidiac C, et al. Non-tuberculous mycobacterial tenosynovitis: a review. Scand J Infect Dis 1999;31:221–8. 18. Eskesen AN, Skramm I, Steinbakk M. Infectious tenosynovitis and osteomyelitis caused by Mycobacterium nonchromogenicum. Scan J Infect Dis 2007;39:179–80. 19. Carbonara S, Tortoli E, Costa D, Monno L, Fiorentino G, Grimaldi A, et al. Disseminated Mycobacterium terrae infection in a patient with advanced human immunodeficiency virus disease. Clin Infect Dis 2000;30:831–5. 108 BW Milne et al. Journal of Orthopaedic Surgery 20. Kuze F, Mitsuoka A, Chiba W, Shimizu Y, Ito M, Teramatsu T, et al. Chronic pulmonary infection caused by Mycobacterium terrae complex: a resected case. Am Rev Respir Dis 1983;128:561–5. 21. Spence TH, Ferris VM. Spontaneous resolution of a lung mass due to infection with Mycobacterium terrae. South Med J 1996;89:414–6. 22. Tonner JA, Hammond MD. Pulmonary disease caused by Mycobacterium terrae complex. South Med J 1989;82:1279– 82. 23. Peters EJ, Morice R. Miliary pulmonary infection caused by Mycobacterium terrae in an autologous bone marrow transplant patient. Chest 1991;100:1449–50. 24. Fujisawa K, Watanabe H, Yamamoto K, Nasu T, Kitahara Y, Nakano M. Primary atypical mycobacteriosis of the intestine: a report of three cases. Gut 1989;30:541–5. 25. Cianciulli FD. The radish bacillus (Mycobacterium terrae): saprophyte or pathogen? Am Rev Respir Dis 1974;109:138– 41. 26. Phillips MS, von Reyn CF. Nosocomial infections due to nontuberculous mycobacteria. Clin Infect Dis 2001;33:1363–74. 27. Wallace RJ Jr, Brown BA, Griffith DE. Nosocomial outbreaks/pseudo-outbreaks caused by nontuberculous mycobacteria. Annu Rev Microbiol 1998;52:453–90. 28. Marchevsky AM, Damsker B, Green S, Tepper S. The clinicopathological spectrum of non-tuberculous mycobacterial osteoarticular infections. J Bone Joint Surg Am 1985;67:925–9. 29. Lockwood WW, Friedman C, Bus N, Pierson C, Gaynes R. An outbreak of Mycobacterium terrae in clinical specimens associated with a hospital potable water supply. Am Rev Respir Dis 1989;140:1614–7. 30. Bettiker RL, Axelrod PI, Fekete T, St John K, Truant A, Toney S, et al. Delayed recognition of a pseudo-outbreak of Mycobacterium terrae. Am J Infect Control 2006;34:343–7. 31. Fung HB, Kirschenbaum HL, Ojofeitimi BO. Linezolid: an oxazlidinone antimicrobial agent. Clin Ther 2001;23:356–91. 32. Reddy VM, O’Sullivan JF, Gangadharam PR. Antimycobacterial activities of riminophenazines. J Antimicrob Chemother 1999;43:615–23.